Miller, W. R. Rollnick, S. (2002). Motivational interviewing Preparing people for change, Second Edition. New York The Guilford Press.

5

Anyone who willingly enters into the pain of a stranger is truly a remarkable person.

Henri J. M. Nouwen

6

When given a choice between changing and proving that it is not necessary, most people get busy with the proof.

John Galbraith

7Are you Ready?Importance and Confidence

How important is it to you now to learn new ways to enhance the motivation of your participants?

How confident are you that you could employ new methods if you wanted to?

8Stages of Change 9Research Evidence Suggests

A cyclical pattern of movement through specific stages of change

A common set of processes of change

A systematic integration of the stages and processes of change (doing the right things at the right times)

10Stages of Change

Precontemplation

Contemplation

Determination/Preparation

Action

Maintenance

Termination

11Stages of ChangePRE-CONTEMPLATION Not yet considering possibility of change.RELAPSE Help renew contemplation, action without giving up. CONTEMPLATION Considers change rejects it.Reasons for concern vs. justifications for concern MAINTENANCE Identify Strategies support to prevent relapse PREPERATION or DETERMINATION Ive got to do something about this problem. This is serious. Something has to change. ACTION 12Stages of Change

Precontemplation No intention to change behavior in the foreseeable future. Individuals in this stage are unaware or underaware of their problem(s).

Not even thinking about it

13The Five Rs of How and Why People Stay in Precontemplation

Reveling

Reluctance

Rebellion

Resignation

Rationalization

14Stages of Change (cont.)

Contemplation A person is aware that a problem exists, are seriously considering changing, and have not yet made a commitment to take action. Contemplators perform a risk-reward analysis.

Thinking about it or maybe

15Stages of Change (cont.)

Preparation Individuals are intending to take action and may practice some of the behaviors necessary.

Getting ready to do it

Action In this stage individuals modify their behavior, experiences, or environment in order to overcome their problems. Doing it

Maintenance Individuals in this stage work to prevent lapse/relapse and consolidate gains. Living it

Termination The problem ceases to be a problem. Moving on

16 STAGES OF CHANGE THERAPIST TASKSRaise doubt - Increase the participants perception of risks and problems with current behaviorPRECONTEMPLATIONTip the decisional balance - Evoke reasons for change, risks of not changing Strengthen self-efficacy for behavior change CONTEMPLATIONHelp to determine the best course of action to take in seeking change Develop a planPREPARATIONHelp implement the plan Use skills Problem solve Support self-efficacyACTIONHelp identify and use strategies to prevent lapse/relapse Resolve associated problemsMAINTENANCEHelp recycle through the stages of contemplation, preparation, and action, without becoming stuck or demoralized because of relapseRELAPSE 17TerminationLeaving the Cycle of Change

Low temptation

High self-efficacy

Firmly established pattern of new behavior

New behavior is normative

Multiple changes in other dimensions to sustain change

18Approaches to Change 19Why Do People Change?

People change voluntarily only when

They become interested in or concerned about the need for change

They become convinced that the change is in their best interests or will benefit them more than cost them

They organize a plan of action that they are committed to implementing

They take the actions that are necessary to make and sustain the change

20Motivational Statements

The beatings will continue until morale improves.

If you dont stop crying, Ill give you something to cry about.

You will take this medicine, because as your Doctor, I say so.

If you dont stop, I guarantee something bad will happen!

21Motivational Approaches

Coercion

Persuasion

Constructive Confrontation

External Contingencies (threats)

Bribe/Incentive

Beg

22

People are generally better persuaded by the reasons they themselves discover than by those that enter the minds of others.

Pascal

23

It is the truth we ourselves speak rather than the treatment we receive that heals us.

O. Hobart Mowrer

24Predictable Effects of Confrontation

Resistance Non-cooperation

Reversal Eliciting the Opposite in Ambivalence

Reactance Assertion of Autonomy

25QWhere does the statementYou have a problem.get you and the participant?A 26In motivational interviewing, confrontation is theGOAL, not a style. 27The purpose of confrontation is to see and accept reality, so one can change accordingly. 28Ambivalence

Conflict between two courses of action

Normal, acceptable, and understandable

Must be resolved to move forward with change and reduce the probability of lapse/relapse

29What is Motivation?

Motivation can be thought of not as a participant attribute, but as an interpersonal process between therapist and participant. Research clearly demonstrates that the interaction between therapist and participant powerfully influences participant resistance, adherence, and change.

30Motivation The Change Process

Participants are not unmotivated. They are just motivated to engage in behaviors that others consider harmful and problematic or are not ready to begin behaviors that others think would be helpful.

Reflect back, selectively, the self-motivational aspects of what the participant states

Affirm and reinforce the participant for making self-motivational statements

47Strategies to Develop Discrepancy

cont....

Offer periodic summaries of self-motivational themes

Use substance use assessment results

48Principles of Motivational Interviewing

Principle 3 Roll with Resistance

Momentum can be used to good advantage

Perceptions can be shifted

New perspectives are invited, not imposed

The participant is a valuable resource in finding solutions

49Principles of Motivational Interviewing

Principle 3 Roll with Resistance, cont.

Avoid arguing for change defending causes defensiveness

Resistance is not directly opposed

Resistance is a signal to respond differently

50Principles of Motivational Interviewing

Principle 4 Support Self-Efficacy

Belief that one can change is an important motivator

The participant is responsible for choosing and carrying out personal change

There is hope in the range of alternative approaches available

The worker's own belief in the persons ability to change becomes a self fulfilling prophecy

51

If you treat an individual as she is, she will stay as she is, but if you treat her as if she were what she ought to be and could be, she will become what she ought to be and could be.

Johann Wolfgang von Goethe

52Phase 1 Building Motivation for Change 53Readiness RulerReady

Ready A matter of priorities

Willing The importance of change

Able Confidence for change

WillingAble 54Importance and Confidence 55Phase I Building Motivation To Change

Some Early Traps to Avoid

Question-Answer Trap

Trap of Taking Sides

Expert Trap

Labeling Trap

Premature-Focus Trap

The Blaming Trap

56Five Early Strategies OARS

Ask Open-ended questions

Affirm Try to reinforce anything that leads to change and builds the relationship.

Listen Reflectively

Summarize

Elicit self-motivational statements

-problem recognition -expression of concern

-intention to change -optimism about change

571. Ask Open Questions

Participant should be doing more than half the talking

Questions that do not invite brief answers

Avoid asking three questions in a row

Exercise Is It an Open or a Closed Question?

582. Listen Reflectively

S Face the participant SQUARELY

O Adopt an OPEN posture

L LEAN toward the participant at times

E Maintain appropriate eye contact

R Be RELAXED

59ExerciseLearning to THINK Reflectively

Reflective listening

One thing I like about myself is

You mean that

The person initiating may only say, yes or no to the reflections

Keep going until you have made five correct reflections.

60Reflective Listening

There are many clinical skills that are helpful when one is doing this work. But the most important skill to develop, in practicing harm reduction work, is that of listening to our clients. They will tell us what they need (Little, 2001, p. 31).

61

It takes two to speak the truth One to speak, and another to hear.

Henry David Thoreau

623. Affirm

Compliments or statements of appreciation and understanding

634. Summarize

Reinforce what has been said

Show that you have been listening carefully

Prepare the participant to elaborate further

Allow participant to hear his or her own change talk for a second or third time

Type of summaries

Collecting

Linking

Transitional

645. Eliciting Change Talk

Invite the participant to give the arguments for change

Types of Change Talk

Disadvantages of the status quo

Advantages of change

Optimism about change

Intention to change

65Methods for Evoking Change Talk

Asking Evocative Questions

Using the Importance Ruler

Exploring the Decisional Balance

Elaborating

Querying Extremes

Looking Back

Looking Forward

Exploring Goals and Values

66Questions that Evoke Self-Motivational Statements

Disadvantages of the status quo

What difficulties have you had in relation to your drug/alcohol use?

In what ways has this been a problem for you?

How does your drug/alcohol use interfere with who you want to be?

What do you think will happen if you dont change?

67Questions that Evoke Self-Motivational Statements

Advantages of change

How would you like for things to be different?

What would be the good things about changing?

What would you like your life to be like a year from now?

What are the main reasons you see for making a change?

68Questions that Evoke Self-Motivational Statements

Optimism about change

If you decided to change, what do you think would work for you?

What makes you think you can change, even if you decided to?

What do you see in yourself in terms of ability that might be encouraging, if you decided to change?

Who could offer you support in making this change?

69Questions that Evoke Self-Motivational Statements

Intention to change

What makes you think you need to do something different?

What would be the advantage to changing your behavior?

What things make you think you should keep drinking the way you do...and on the other side...what makes you think you should change?

70Decisional Balance

Ambivalence is a normal part of the process of change

Use conflict to promote positive change

Weighing pros and cons of behavior

Highlighting discrepancy

Most useful in Precontemplation and Contemplation stages as a tool to increase motivation

71(No Transcript) 72Decisional Balance Worksheet 73Decisional Balance Worksheet 74Thinking About Drinking Here is an example of a woman drinker. Remember, every person has different reasons in their decisional consideration about drinkingGood things about my drinkingGood things about changing my drinkingMore relaxed Will not have to think about my problems for a while More comfortable with drinking friendsMore control over my life Support from family and friends Less legal trouble Better healthNot so good things about my drinking Not so good things about changing my drinkingDisapproval from family and friends Increased chance of legal and job trouble Costs too much moneyMore stress or anxiety Feel more depressed Increased boredom 75Conducting a Decisional Balance Discussion

Accept all answers. (Avoiding arguing with/disputing answers given by participant).

Explore answers.

Be sure to note both the benefits and costs of current behavior and change.

Explore costs/benefits with respect to participants goals and values.

Review the costs and benefits.

76Exercise

Conduct a decisional balance discussion about the pros and cons of changing some aspect of his/her life, e.g., exercise, smoking, drinking, or diet.

77Resistance

Arises from the interpersonal interaction between counselor and participant

The participants way of communicating that the therapist and participant are at different places

talks about how life could be after a change, or discusses advantages of change

Experimenting

begins to try different change approaches

93

We found thatdrinkers would not take pressure in any form, excepting from John Barleycorn himself. They always had to be led, not pushedWe found we had to make haste slowly.

Bill Wilson

94Strengthening Commitment to Change

The goals are to channel intrinsic motivation into a negotiated, workable plan for change and to strengthen the participant's commitment for carrying out that plan.

Does not involve telling people what they must do, but rather, eliciting what they want and plan to do.

95Strategies for Strengthening Commitment

A few potential hazards

Underestimating Ambivalence

Over-prescription

Insufficient Direction

96Strategies for Strengthening Commitment

Recapitulation

-a summary of participants own perception of the problem

-a summing up of the ambivalence

-a review of the objective evidence

-a restatement of participant offerings of wanting, intending, or planning to change

-your own assessment of participants situation, particularly when it matches the participants

97Strategies for Strengthening Commitment

Key Questions to get the participant talking and thinking about change

-what do you think you will do?

-what does all this mean about your use?

-what do you think has to change?

-what could you do, what are your options?

-it sounds like things cant stay the same, what can you do?

98Strategies for Strengthening Commitment

Key Questions cont...

-how would you like things to turn out for yourself?

-of the things that concern you, what are the most important reasons to change?

-what concerns you about changing?

-what would be some of the benefits of changing?

99Strategies for Strengthening Commitment

Giving Information and Advice

Quite possible and appropriate to share ones expertise

When a person requests it

With the persons permission

100Giving Information and Advice

Have I elicited the participants own ideas and knowledge on this subject?

Is what I am going to convey important to the participants safety, or likely to enhance the participants motivation for change?

Have I asked the participants permission to share some advice?

101Giving Information and Advice

Respect, choice, collaboration

Use qualifiers

Dont be too eager to offer advice

Offer a cluster of options

Solicit request from the person for information and advice

102Remember

Talk less than the participant does

On average, reflect twice for each question you ask

When you reflect, use complex reflections more than half the time

103Remember

When you do ask questions, ask mostly open questions

Avoid getting ahead of your participants readiness (warning, confronting, giving unwelcome advice or direction, taking the good side of an argument)

104Additional Resources

www.motivationalinterview.org

TIP 35 available from www.ncadi.gov

The books First Second Editions

Articles

Additional training and supervision

105

I have not the right to want to change another if I am not open to be changed.

Martin Buber

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